Ventriculostomy Placement Research Articles

SURG-27. TREATING HYDROCEPHALUS IN DIFFUSE MIDLINE GLIOMAS WITH AN H3 K27M MUTATION

Abstract BACKGROUND Diffuse midline gliomas (DMG) are a subset of malignant gliomas that share a characteristic Histone H3K27M mutation. These tumors are centrally located and may cause hydrocephalus on initial presentation. DMG lack characteristic imaging that distinguish from other primary brain tumors in the midline. We conducted this retrospective chart review of 43 consecutive patients presenting with midline tumors to determine: how many had a DMG; whether DMG patients with hydrocephalus were candidates for resection; and what the outcomes of endoscopic third ventriculostomy (ETV) versus ventriculoperitoneal shunt (VPS) placement were, as compared to wild type (WT) tumors. METHODS We conducted an IRB approved retrospective chart review of patients presenting with midline tumors from 9/2016-3/2020 to determine H3K27M mutation status, hydrocephalus, and neurosurgery intervention. RESULTS The median age of all midline tumor patients was 19.1 years (range 1.1-80.1). 26% (11/43) of midline tumors presented with H3K27M mutation, with a higher rate of hydrocephalus compared to patients without mutation [7/11 (65%) for DMG vs. 6/32 (19%) for WT, p< 0.05]. Of the seven H3K27M patients presenting with hydrocephalus, none were candidates for resection, 5 underwent ETV, and 2 underwent VPS placement as initial management. 4 out of these 5 ETVs failed within an average of 24 days (6-42 days). 2 patients then underwent VP shunt placement; the other 2 underwent secondary ETV but both failed and required VP shunting as well. All 6 WT tumor patients had one procedure (1 ETV, 5 resection) to relieve hydrocephalus, and no patients had recurrent hydrocephalus. CONCLUSIONS Both pediatric and adult patients may present with DMG associated with a higher rate of unresectable tumors and hydrocephalus on presentation. Furthermore, these data suggest that neuroendoscopic third ventriculostomy and septum pellucidum fenestration for the management of obstructive hydrocephalus in patients with DMG may be less robust than shunting.

CSF Leaks due to Electric Scooter Injury

There has been a rapid increase in electric motorized scooter (e-scooter) usage after the introduction of dockless, shareable devices. Case series from three tertiary hospitals in Los Angeles between May-September 2019. Five patients had skull base fractures and CSF leaks or pneumocephalus after e-scooter accident, none wore helmets. Two patients were treated with observation alone, two patients were treated with lumbar drain or external ventriculostomy placement, and one patient died of their injuries prior to definitive management. Without appropriate safety policies in place, the number of such injuries may increase as the use of e-scooters increase. Laryngoscope, 131:E1035-E1037, 2021.

Abstract P072: Hypertensive Emergency Presenting With Intraventricular Hemorrhage

A 34-year-old African American female with a past medical history of hypertension and medical noncompliance presented to the emergency department after being found down and unresponsive by her son. On presentation, the patient's blood pressure was found to be 298/194 with a Glasgow coma score of 4, with decerebrate posturing. The computed tomography of the head showed large acute intraventricular hemorrhage in the right lateral ventricle extending along the frontal horn into the left lateral ventricle, third and fourth ventricles, causing a 4 mm leftward shift. The patient was managed with a Nicardipine drip and underwent a bilateral ventriculostomy placement, which improved the patient's neurologic status. Following a 24 day hospital stay, the patient was alert and oriented without any significant neurologic deficits and discharged to a subacute rehab facility. Hypertension is one of the most common medical conditions affecting 50 million people in the United States and approximately 1 billion people worldwide. Approximately 1% of patients with hypertension will have a hypertensive emergency at some point in their life. The clinical manifestations of hypertensive emergencies are seen with organ dysfunction, which typically require diastolic blood pressures greater than 130mmHg, in nonpregnant adults. A severe outcome of hypertensive emergency is an intracerebral hemorrhage. In these patients, when the bleed extends into the ventricles, the mortality ranges from 50-80%. One study examined medical compliance in hypertensive patients, which showed approximately 40% of patients discontinued treatment one year after initiation of their antihypertensive medication and 4% never initiated therapy. This case illustrates the importance of compliance in hypertensive patients, as well as the dramatic ramifications that can occur with uncontrolled hypertension leading to hypertensive emergency.

Ventriculostomy with subsequent ventriculoperitoneal shunt placement after subarachnoid hemorrhage: the effect of implantation site on postoperative complications-a single-center series.

Patients suffering from aneurysmal subarachnoid hemorrhage (SAH) with shunt-dependent hydrocephalus require subsequent placement of a ventriculoperitoneal shunt (VPS) after ventriculostomy. However, in patients with previous ventriculostomy, the site for proximal VPS catheter placement is still controversial. We investigated the effect of catheter placement on postoperative complications by analyzing patients with ventriculostomy and subsequent VPS placement after SAH. From January 2004 to December 2018, 164 of 1128 patients suffering from SAH underwent subsequent VPS placement after ventriculostomy in the authors' institution. Patients were divided into two groups according to the position of the ventriculostomy and the site of the proximal VPS catheter ("same site" group versus "contralateral site" group). VPS-related infectious and bleeding complications following VPS placement were assessed and analyzed. Overall, VPS-related infections occurred in 11 of the 164 patients (7%). Furthermore, five of the 164 patients (3%) suffered from VPS-related hemorrhage. However, VPS infection rate was lower 5% (6/115) in the same site compared to 10% (5/49) in the contralateral site group, although without reaching statistical significance (OR = 0.48 (0.14, 1.67) 95% confidence interval, p = 0.3). VPS-related hemorrhage rate did not differ significantly between patients in the same site group (3.5%, 4/115) and the contralateral site group (2.0%, 1/49; OR = 1.73 (0.18, 15.9), p = 1.0). Our study suggests that the use of the ventriculostomy site for VPS placement does not significantly increase the risk of either VPS-related infections or VPS-related hemorrhages.

In Reply: The Safety and Efficacy of Continuous Tirofiban as a Monoantiplatelet Therapy in the Management of Ruptured Aneurysms Treated Using Stent-Assisted Coiling or Flow Diversion and Requiring Ventricular Drainage.

Background Hemorrhagic complications are a major concern for aneurysmal subarachnoid hemorrhage patients treated with stenting or stent-assisted coiling and undergoing additional procedures such as shunting, ventriculostomy placement, and craniotomies/craniectomies. Objective To assess the safety and efficacy of using a continuous infusion of tirofiban as a monoantiplatelet therapy in the management of ruptured aneurysms in the setting of either stent-assisted coiling (SAC) or flow diversion devices (FDD) in patients requiring either an external ventricular drain (EVD) or ventriculoperitoneal shunt (VPS). Methods Aneurysmal subarachnoid hemorrhage (aSAH) patients between July 2017 and September 2018 who were treated with SAC or FDD were started on a continuous tirofiban infusion protocol (0.10 μg/kg/min) with no preceding loading dose as a monoantiplatelet therapy. Safety analysis was performed retrospectively to assess the complication rate, hemorrhagic rate, and rate of ischemic events. There were no hemorrhages related to the VPS surgery. Results Nineteen subjects were included in the series. The patients received a total of 25 procedures that included 19 EVDs and 6 VPSs. Two patients (8.3%) developed small asymptomatic track hemorrhages after EVD placement. One patient developed a large retroperitoneal hemorrhage due to renal artery branch injury during procedure, and another patient developed an idiosyncratic transient thrombocytopenia which resolved after stopping the medication. One patient (4%) developed a transient ischemic attack, which resolved after a bolus of tirofiban. Conclusion Our study suggests that long-term use of intravenous tirofiban monotherapy in aSAH subjects for endovascular SAC or FDD is safe in the perioperative setting.

The Safety and Efficacy of Continuous Tirofiban as a Monoantiplatelet Therapy in the Management of Ruptured Aneurysms Treated Using Stent-Assisted Coiling or Flow Diversion and Requiring Ventricular Drainage.

Hemorrhagic complications are a major concern for aneurysmal subarachnoid hemorrhage patients treated with stenting or stent-assisted coiling and undergoing additional procedures such as shunting, ventriculostomy placement, and craniotomies/craniectomies. To assess the safety and efficacy of using a continuous infusion of tirofiban as a monoantiplatelet therapy in the management of ruptured aneurysms in the setting of either stent-assisted coiling (SAC) or flow diversion devices (FDD) in patients requiring either an external ventricular drain (EVD) or ventriculoperitoneal shunt (VPS). Aneurysmal subarachnoid hemorrhage (aSAH) patients between July 2017 and September 2018 who were treated with SAC or FDD were started on a continuous tirofiban infusion protocol (0.10 μg/kg/min) with no preceding loading dose as a monoantiplatelet therapy. Safety analysis was performed retrospectively to assess the complication rate, hemorrhagic rate, and rate of ischemic events. There were no hemorrhages related to the VPS surgery. Nineteen subjects were included in the series. The patients received a total of 25 procedures that included 19 EVDs and 6 VPSs. Two patients (8.3%) developed small asymptomatic track hemorrhages after EVD placement. One patient developed a large retroperitoneal hemorrhage due to renal artery branch injury during procedure, and another patient developed an idiosyncratic transient thrombocytopenia which resolved after stopping the medication. One patient (4%) developed a transient ischemic attack, which resolved after a bolus of tirofiban. Our study suggests that long-term use of intravenous tirofiban monotherapy in aSAH subjects for endovascular SAC or FDD is safe in the perioperative setting.

VP101 Intrauterine Surgical Interventions: A Rapid Review

IntroductionAdverse conditions during pregnancy, such as myelomeningocele (MMC), fetal-fetal transfusion syndrome (STFF) and congenital heart disease (CHD) not only significantly increase the risk of fetal death, but also increase the occurrence of severe postnatal sequelae.MethodsWe conducted a rapid review of the efficacy and safety of intrauterine interventions in MMC, STFF and DCC in comparison to traditional interventions. We searched Pubmed via Medline, Cochrane Library and Center for Reviews and Dissemination databases using the terms indexed and synonyms for each intervention.ResultsFor STFF, the available scientific evidence indicates that laser ablation is effective and presents better outcomes when compared to other interventions, such as high overall survival rate, better perinatal outcomes and less chance of brain injury. Even though intrauterine interventions in CHD present high rates of live births, high neonatal mortality rates are also reported. Evidence on the efficacy and safety of intrauterine surgical interventions for myelomeningocele and CHD is inconclusive. Regarding myelomeningocele, no significant differences were observed for the outcomes of postnatal mortality, rate of ventriculostomy placement, reversal of posterior brain herniation, motor response and placental rupture.ConclusionsThere is no consensus regarding the efficacy and safety of intrauterine surgical interventions for myelomeningocele and CHD. Regarding STFF, laser ablation is accepted as an effective intervention. It is necessary to conduct prospective studies in order to evaluate the effect of these interventions, considering the specifications of each condition and the ethical aspects.

Factors Predicting Ventriculostomy Revision at a Large Academic Medical Center

Freehand bedside ventriculostomy placement can result in catheter malfunction requiring a revision procedure and cause significant patient morbidity. We performed a single-center retrospective review to assess factors related to this complication. Using an administrative database and chart review, we identified 101 first-time external ventricular drain placements performed at the bedside. We collected data regarding demographics, medical comorbidities, complications, and catheter tip location. We performed univariate and multivariate statistical analyses using MATLAB. We corrected for multiple comparisons using the false discovery rate (FDR) procedure. Multivariate regression analyses revealed that revision procedures were more likely to occur after drain blockage (odds ratio [OR] 17.9) and hemorrhage (OR 10.3, FDR-corrected P values < 0.01, 0.05, respectively). Drain blockage was less frequent after placement in an "optimal location" (ipsilateral ventricle or near foramen of Monroe; OR 0.09, P= 0.009, FDR-corrected P < 0.03) but was more likely to occur after placement in third ventricle (post-hoc P values < 0.015). Primary diagnoses included subarachnoid hemorrhage (n= 30, 29.7%), intraparenchymal hemorrhage with intraventricular extravasation (n= 24, 23.7%), tumor (n= 20, 19.8%), and trauma (n= 17, 16.8%). Most common complications included drain blockage (n= 12, 11.8%) and hemorrhage (n= 8, 7.9%). In total, 16 patients underwent at least 1 revision procedure (15.8%). Bedside external ventricular drain placement is associated with a 15% rate of revision, that typically occurred after drain blockage and postprocedure hemorrhage. Optimal placement within the ipsilateral frontal horn or foramen of Monroe was associated with a reduced rate of drain blockage.

Complicated Case of Acute Fatty Liver of Pregnancy Without Deadly Outcome: Case Report

Background: Acute fatty liver of pregnancy (AFLP) is a rare disorder during pregnancy which is associated with microvesicular fatty infiltration of hepatocytes. We present a patient who was admitted with acute fatty liver of pregnancy. Case: 27-year old female gravida1, para 0 with a past medical history of gestational hypertension presented at her 32 weeks of gestation with uncontrolled hypertension; which evolved to preeclampsia. The patient was complaining of right upper quadrant pain and headache and had moderate tenderness in the right upper quadrant. Initially she received hydralazine, magnesium sulfate and betamethasone. Emergency cesarean section was done for fetal distress and severe preeclampsia. Her presentation was complicated with seizure requiring intubation. Initial labs showed: Na 129 ((mEq/L) K 6.3 (mEq/L) CO2 18 ((mEq/L) Creatinine 2.7 MG/DL) Magnesium 7.7 (mEq/L) phosphorus 7.9 (MG/DL) AST 3323 (U/L) ALT 2618 (U/L) WBC 24.5 (x109/L) hemoglobin 7.4 (MG/DL) platelets 70 (x109/L) INR 1.40 D Dimer 8418 (NG/ML) Fibrinogen 41(MG/DL) Uric acid 11.5 MG/DL). Patient AFLP was complicated by disseminated intravascular coagulation, intra-abdominal and intrahepatic/subscapular liver hematoma and hemoperitonium requiring emergent and laparotomy. She received multiple transfusions of packed red blood cells, fresh frozen plasma and cryoprecipitates. Head CT showed scattered parenchymal hemorrhage with significant intraventricular extension and development of obstructive hydrocephalus. She had emergent ventriculostomy placement followed by decompression craniotomy with bone flap removal.She had acute kidney injury requiring renal replacement therapy. Her protracted course ended up with discharged to a rehab facility after about 2 months of hospitalization. Later her neurological exam improved significantly. During rehabilitation, patient was able to practice with the treadmill, but she continued to have muscle stiffness. Discussion: AFLP is considered as an autosomal recessive genetic disorder. and considered as a diagnosis of exclusion.Labratory data such as Uric acid, ammonia and glocuse might assist with establishing the diagnosis.. About half of the patinets have PE/HELLP syndrome and this makes the initial diagnosis challenging. AFLP carries high mortality rate wich prompt multidisciplinary involvement is required to mange this condition in collaborative fashion to prevent fatal outcomes.2391_A Figure 1. CT head-scattered parenchymal hemorrhage within the right basal ganglia as well as corpus callosum, as described above, with significant intraventricular extension and development of obstructive hydrocephalus.2391_B Figure 2. CT abdomen- moderate ascites/hemoperitoneum. The heterogeneous density lateral to the liver is likely evolving hemorrhage.2391_C Figure 3. US of the liver showed small to moderate fluid lateral to the liver. Edematous and thick gallbladder wall.

Evaluation of alpha-II-spectrin breakdown products as potential biomarkers for early recognition and severity of aneurysmal subarachnoid hemorrhage

This study assessed whether cytoskeletal protein alpha-II spectrin breakdown products (SBDP150, SBDP145, and SBDP120) would identify the presence of aSAH and be associated with severity (GCS score, WFNS grade and survival to hospital discharge). This prospective case-control study, conducted at a tertiary care Level I trauma center, enrolled adult patients with angiography confirmed aSAH who underwent ventriculostomy placement for cerebrospinal fluid (CSF) drainage. There were 40 patients enrolled in the study, 20 with aSAH and 20 control subjects. Patients with aSAH were a mean age of 54 (SD15) and 75% were female. There were significant differences in SBDP150, SBDP145, and SBDP120 CSF levels between patients with and without aSAH (p < 0.001), even in those presenting with a GCS Score of 15 and a WFNS Grade 1. The AUC for distinguishing aSAH from control subjects was 1.0 for SBDP150 and SBDP145, and 0.95 for SBDP120. SBDP150 and SBDP145 both yielded sensitivities and specificities of 100% and SBDP120 was 90% and 100% respectively. Moreover, there were significantly higher levels of SBDP150 and SBDP145 in the non-survivors than in the survivors (p < 0.001). This study demonstrates the potential that SBDP’s have as biomarkers for recognition and severity of aSAH. A larger prospective study is warranted.

Isolated subdural hematomas in mild traumatic brain injury. Part 1: the association between radiographic characteristics and neurosurgical intervention.

Isolated subdural hematomas (iSDHs) are one of the most common intracranial hemorrhage (ICH) types in the population with mild traumatic brain injury (mTBI; Glasgow Coma Scale score 13-15), account for 66%-75% of all neurosurgical procedures, and have one of the highest neurosurgical intervention rates. The objective of this study was to examine how quantitative hemorrhage characteristics of iSDHs in patients with mTBI at admission are associated with subsequent neurosurgical intervention. This was a 3.5-year, retrospective observational cohort study at a Level I trauma center. All adult trauma patients with mTBI and iSDHs were included in the study. Maximum length and thickness (in mm) of acute SDHs, the presence of acute-on-chronic SDH, mass effect, and other hemorrhage-related variables were double-data entered; discrepant results were adjudicated after a maximum of 4 reviews. Patients with coagulopathy, skull fractures, no acute hemorrhage, a non-SDH ICH, or who did not undergo imaging on admission were excluded. The primary outcome was neurosurgical intervention (craniotomy, burr hole, catheter drainage of SDH, placement of intracranial pressure monitor, shunt, or ventriculostomy). Multivariate stepwise logistic regression was used to identify significant covariates and to assess interactions. A total of 176 patients were included in our study: 28 patients did and 148 patients did not receive a neurosurgical intervention. Increasing head Abbreviated Injury Scale score was significantly associated with neurosurgical interventions. There was a strong correlation between the first 3 reviews on maximum hemorrhage length (R2 = 0.82) and maximum hemorrhage thickness (R2 = 0.80). The neurosurgical intervention group had a mean maximum SDH length and thickness that were 61 mm longer and 13 mm thicker than those of the nonneurosurgical intervention group (p < 0.001 for both). After adjusting for the presence of an acute-on-chronic hemorrhage, for every 1-mm increase in the thickness of an iSDH, the odds of a neurosurgical intervention increase by 32% (95% CI 1.16-1.50). There were no interventions for any SDH with a maximum thickness ≤ 5 mm on initial presenting scan. This is the first study to quantify the odds of a neurosurgical intervention based on hemorrhage characteristics in patients with an iSDH and mTBI. Once validated in a second population, these data can be used to better inform patients and families of the risk of future neurosurgical intervention, and to evaluate the necessity of interhospital transfers.

Diagnosis, Classification, and Management of Fourth Ventriculomegaly in Adults: Report of 9 Cases and Literature Review

An enlarged fourth ventricle, otherwise known as fourth ventriculomegaly (4th VM), has been reported previously in the pediatric population, yet literature on adults is scant. We report our experience with 4th VM in adults over an 11-year period and review the literature. This was a retrospective chart review of adult patients with the diagnosis of 4th VM admitted to the intensive care unit in a tertiary care center. Nine patients were identified with 4th VM. Most presented with symptoms in the posterior fossa. Five cases were related to previous shunting and the underlying neurosurgical diseases, and average time interval to develop symptoms was 5.3 years. We divided our cases into primary, acquired, and degenerative based on the pathophysiology involved. Treatments included extended subzero cerebrospinal fluid diversion using a frontal external ventricular drain followed by low-pressure shunt revision, endoscopic third ventriculostomy, suboccipital decompression, and fourth ventricular catheter placement. Literature review identified additional published cases, and there were no reports of a formal classification scheme or treatment algorithm. This case series illustrates a narrow spectrum of etiologies associated with 4th VM in adults. We propose a simple classification scheme dividing 4th VM into 3 categories: primary, acquired, and degenerative. We recommend a stepwise treatment approach starting with extended subzero cerebrospinal fluid diversion followed by shunting for symptomatic primary and acquired 4th VM. Lower success rates and greater morbidity are associated with rescue procedures such as fourth ventricle drainage catheters, endoscopic third ventriculostomies, and skull base decompression.

Endoscopic third ventriculostomy versus ventriculoperitoneal shunt placement in children with obstructive hydrocephalus

Background: Uncertainty persists on the best treatment for patients with obstructive hydrocephalus: endoscopic third ventriculostomy (ETV) or ventriculoperitoneal shunt (VPS), particularly in the younger age groups. The author investigated and compared 1-year outcomes for ETV and VPS treatment categories at Zewditu Memorial Hospital (ZMH), Ethiopia.Methods: This was a retrospective, hospital-based study. The study reviewed 259 paediatric patients with hydrocephalus in whom VPS or ETV with or without choroid plexus cauterisation (CPC) was done as a primary treatment, between January 2013 and January 2016 at ZMH. Patients’ medical records, operative notes, and neural tube database records were used to complete a structured questionnaire. The difference in proportions was examined using the chi-square test.Results: Sixty-seven (25.9%) children initially underwent ETV and 192 (74.1%) underwent VPS placements. The median age was 5 months (range 3 days-168 months). Children who underwent VPS placement rather than ETV had a statistically significant higher risk of postoperative infection (27.0% vs 6.1%; P = 0.001), complications (27.0% vs 12.2%; P = 0.025), and a higher but insignificant operative failure rate at 1 year (45.3% vs 38.8%; P = 0.27). Sex and age were not associated with the occurrence of complications, while VPS and myelomeningocele or encephalocele (MMC/EC) were strongly associated. Complication and infection were significantly and negatively associated with complication-free 1-year survival rate (P &lt; 0.001 each), while gender, age, procedure, and cause of hydrocephalus did not show any association with survival. There was a significant reduction of VPS success rate from 76.9% at 6 months postsurgery to 54.7% at 1 year (P &lt; 0.001), while ETV success rate remained constant during the same period (66.7% and 61.2%, respectively). Mortality frequencies for ETV and VPS insertion were 3 (4.5%) and 9 (4.7%), respectively, for a combined total of 12 deaths (4.6%).Conclusions: Sex and age were not associated with complications, while VPS and MMC/EC were strongly associated. Children who underwent VP shunt placement rather than ETV had a higher risk of postoperative infection and complications, but there was no difference in operative failure or success rate and mortality rates between the procedures. ETV failure rate was less likely after 6 months.Keywords: obstructive hydrocephalus; endoscopic third ventriculostomy; ventriculoperitoneal shunt; children; paediatric surgery; neurosurgery; Ethiopia

Variability in the Use of Platelet Transfusion in Patients with Intracerebral Hemorrhage: Observations from the Ethnic/Racial Variations of Intracerebral Hemorrhage Study

We examined platelet transfusion (PTx) in the Ethnic/Racial Variations of Intracerebral Hemorrhage (ERICH) study, hypothesizing that rates of PTx would vary among hospitals and depend on whether patients were on an antiplatelet therapy or underwent intracerebral hemorrhage (ICH) surgical treatment. The ERICH study is a prospective observational study evaluating risk factors for ICH among whites, blacks, and Hispanics. We identified factors associated with PTx, examined practice patterns of PTx across the United States, and explored the association of PTx with mortality and poor outcome (modified Rankin Scale score 4-6). Nineteen centers enrolled 2572 ICH cases; 11.7% received PTx. Factors significantly associated with PTx were antiplatelet use before onset (odds ratio [OR], 5.02; 95% confidence interval [CI], 3.81-6.61, P < .0001), thrombocytopenia (OR, 13.53; 95% CI, 8.43-21.72, P < .0001), and ventriculostomy placement (OR, 1.85; 95% CI, 1.36-2.52, P < .0001). Blacks were less likely (OR, .57; 95% CI, .41-0.80) to receive PTx. Among patients who received PTx, 42.4% were not on an antiplatelet therapy before onset. Twenty-three percent of patients on antiplatelet therapy received PTx, but percentages varied from 0% to 71% across centers. There was no difference in mortality or poor outcome at 3 months between patients receiving PTx and those who did not. The frequency of PTx for ICH varies across academic centers. Thrombocytopenia, antiplatelet use, vascular risk factors, and ventriculostomy placement were associated with PTx. PTx was not associated with improved outcomes. We anticipate reduced PTx use over time given recent clinical trial data suggesting its use could be harmful; however, the issue of whether surgical management warrants PTx remains.

Timing of Permanent Ventricular Shunt Placement Following External Ventricular Drain Placement in Primary Intracerebral Hemorrhage

Intraventricular hemorrhage requiring ventriculostomy placement is a frequent complication of spontaneous intracerebral hemorrhage. Although a subset of patients will require permanent ventricular shunt placement, little is known about contemporary practices regarding the timing of ventriculostomy and ventricular shunt placement after intracerebral hemorrhage. Using the 2010-2012 National Inpatient Sample, we identified patients with International Classification of Diseases, Ninth Revision codes for intracerebral hemorrhage, excluded secondary causes, and examined procedure dates. Of 35,899 patients with primary intracerebral hemorrhage, 2443 (6.8%) received ventriculostomy, 93% within the first 3 days of admission and 66% within the first day. Permanent shunt placement occurred in 173 (7.1%) patients following ventriculostomy at a median interval of 15 days (interquartile range: 11-20). Among those remaining alive and in hospital at 14, 21, and 28 days, 5%, 11%, and 15%, respectively, underwent shunt placement following ventriculostomy, and 24% of those with multiple ventriculostomy insertions required permanent shunt by 4 weeks of hospitalization. Multiple ventriculostomies, tracheostomy, and black race were associated with longer time to permanent shunt. A wide variation in delay to permanent shunt placement is present, with substantial and increasing prevalence with time in hospital. Better understanding of the risk factors associated with persistent hydrocephalus will help optimize patient selection and timing of treatment.

Routine neurosurgical consultation is not necessary in mild blunt traumatic brain injury.

The Brain Trauma Foundation guidelines provide indications for neurosurgical intervention in traumatic brain injury (TBI) with moderate or severe intracranial hemorrhage (ICH). In TBI patients with less severe ICH, the utility of neurosurgical consultation remains unclear. We sought to determine if routine neurosurgical consultation is necessary for mild blunt TBI patients with ICH. A retrospective cohort study was conducted on 500 consecutive blunt TBI patients aged 15 years or older with Glasgow Coma Scale score of ≥13 and ICH on initial head computed tomography admitted to a Level I trauma center over 28 months. Outcomes were neurosurgical intervention (craniotomy, craniectomy, ventriculostomy, or intracranial pressure monitor placement) and in-hospital mortality. Statistical significance was assessed at a p < 0.05. Of 500 patients, 49 (9.8%) underwent neurosurgical intervention. Neurosurgical intervention was more frequent in male patients (75.5% vs. 61.2%, p = 0.049), patients with higher head Abbreviated Injury Scale score (4.7 vs. 3.8, p < 0.0001), patients with an abnormal initial neurological examination (30.6% vs. 12.6%, p = 0.001), or patients with skull fracture (28.6% vs. 16.0%, p = 0.026) and was associated with higher mortality (8.2% vs. 2.0%, p = 0.010). Neurosurgical intervention was not associated with intoxication, preinjury antiplatelet/anticoagulation agents, or progression of ICH on second head computed tomography. Neurosurgical consultation was documented in 466 patients (93.2%). For patients without neurosurgical intervention, consultation did not change management. Routine neurosurgical consultation for blunt TBI with ICH seems unnecessary, regardless of intoxication or preinjury antiplatelet or anticoagulation therapy. A more selective approach is warranted to decrease hospital charges and optimize use of neurosurgical consultation. Care management study, level IV.

Abstract TP327: Timing of Ventriculostomy and Ventricular Shunting for Intracranial Hemorrhage: A National Inpatient Sample Study

Background: Intraventricular hemorrhage requiring ventriculostomy (EVD) placement is a frequent complication of spontaneous intracerebral hemorrhage (ICH). Urgent EVD may be warranted for management of acute hydrocephalus, and a subset of these patients will require permanent ventricular shunt (VS) placement. In contrast to hydrocephalus following sub-arachnoid hemorrhage, less is known about the frequency and timing of EVD and VS placement after ICH. Methods: Using the 2010-2012 National Inpatient Sample, we selected patients with ICD-9 codes for ICH, excluded secondary causes, and examined procedure dates for EVD and VS placement. Results: Of 35,991 primary ICH patients, 2,392 (6.7%) received an EVD, 89% within the first 3 days of admission and 64% within the first day. Placement of a VS occurred in 268 patients (0.7%) overall. VS placement occurred in 143 of 2,129 (6.7%) of those receiving an EVD in the first 72 hours and 34 of 263 (12.9%) receiving an EVD after 72 hours (p&lt;0.001). Median time to shunt placement following EVD was 15 days (IQR 11-21) vs 16.5 (IQR 13-21) for those with EVD within vs after 72 hours (p=0.2). 82 (0.2%) received a VS without an initial EVD at a median of 14 days (IQR 9-18). Kaplan-Meier analysis revealed that among those remaining alive and in hospital at 14 and 21 days, 5% and 11%, respectively, underwent shunt placement following EVD. To analyze the effect of VS timing following EVD, we compared those undergoing VS in the first two weeks versus later than two weeks. Following multivariate logistic regression, only age 70 -80 was associated with early shunt placement (OR 4.8, 95%CI 1.2-19). No effect on mortality or rate of home discharge was seen. Length of stay was shorter in those with early versus later VS (20 vs 32 days, p&lt;0.001) Conclusion: Persistent hydrocephalus following EVD placement for ICH is rare overall but VS is required in up to 12% of a subset of patients. EVD placement after the initial 72 hours was associated with an increased rate of VS, while older age was associated with earlier VS placement after EVD. Better understanding of the risk factors associated with persistent hydrocephalus will help optimize patient selection and timing of treatment.

Ventriculostomy-associated hemorrhage: a risk assessment by radiographic simulation.

OBJECTIVE Ventriculostomy entry sites are commonly selected by freehand estimation of Kocher's point or approximations from skull landmarks and a trajectory toward the ipsilateral frontal horn of the lateral ventricles. A recognized ventriculostomy complication is intracranial hemorrhage from cortical vessel damage; reported rates range from 1% to 41%. In this report, the authors assess hemorrhagic risk by simulating traditional ventriculostomy trajectories and using CT angiography (CTA) with venography (CTV) data to identify potential complications, specifically from cortical draining veins. METHODS Radiographic analysis was completed on 50 consecutive dynamic CTA/CTV studies obtained at a tertiary-care academic neurosurgery department. Image sections were 0.5 mm thick, and analysis was performed on a venous phase that demonstrated high-quality opacification of the cortical veins and sagittal sinus. Virtual ventriculostomy trajectories were determined for right and left sides using medical diagnostic imaging software. Entry points were measured along the skull surface, 10 cm posteriorly from the nasion, and 3 cm laterally for both left and right sides. Cannulation was simulated perpendicular to the skull surface. Distances between the software-traced cortical vessels and the virtual catheter were measured. To approximate vessel injury by twist drill and ventricular catheter placement, veins within a 3-mm radius were considered a hemorrhage risk. RESULTS In 100 virtual lines through Kocher's point toward the ipsilateral ventricle, 19% were predicted to cause cortical vein injury and suspected hemorrhage (radius ≤ 3 mm). Little difference existed between cerebral hemispheres (right 18%, left 20%). The average (± SD) distance from the trajectory line and a cortical vein was 7.23 ± 4.52 mm. In all 19 images that predicted vessel injury, a site of entry for an avascular zone near Kocher's point could be achieved by moving the trajectory less than 1.0 cm laterally and less than 1.0 cm along the anterior/posterior axis, suggesting that empirical measures are suboptimal, and that patient-specific coordinates based on preprocedural CTA/CVA imaging may optimize ventriculostomy in the future. CONCLUSIONS In this institutional radiographic imaging analysis, traditional methods of ventriculostomy site selection predicted significant rates of cortical vein injury, matching described rates in the literature. CTA/CTV imaging potentiates identification of patient-specific cannulation sites and custom trajectories that avoid cortical vessels, which may lessen the risk of intracranial hemorrhage during ventriculostomy placement. Further development of this software is underway to facilitate stereotactic ventriculostomy and improve outcomes.

Rates of iatrogenic ventriculitis before and after the use of an alcohol-impregnated external ventricular drain port cap.

Iatrogenic ventriculitis is a potential complication of ventriculostomy drain placement. In this study, an alcohol-impregnated external ventricular drain port cap was added to a standardized ventriculostomy placement bundle. Rates of ventriculitis were reduced postintervention, but this finding did not reach statistical significance.

A Colombian-based survey on ventriculostomy and intracranial pressure monitor placement practices

Objective: Monitoring of intracranial pressure (ICP) is a routine procedure in the neurosurgery field. Although the routine practice of monitoring ICP has decreased in recent years, the practice patterns have not been studied in Colombia. This study was designed to evaluate the current practice forventriculostomy and ICP monitoring by neurosurgeons in Colombia. Methods: An 11-question electronic survey was delivered to 380 practicing neurosurgeons.Demographic information and rates of proper ventriculostomy placement for monitoring of ICP were described. Results:Fifty-one percent of practicing neurosurgeons responded to the survey (response rate 13.4%). The rate of successful cannulation of the ipsilateral ventricle ranged from 70% to 100%. Conclusion:This survey shows that Colombian neurosurgeons have similar tendencies to other developed countries. Prospective studies are necessary to establish actual evidence-based practices